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Table 1 Elements of the planned care management intervention

From: Development of a primary care-based complex care management intervention for chronically ill patients at high risk for hospitalization: a study protocol

Chronic Care Model Element Planned care management component
Clinical information systems Software-based case finding (predictive modelling)
Recall-reminder in electronic medical records
Self management support Collaborative goal setting and action planning, individualized care plans
Patient education (symptom monitoring checklist, advise how to deal with deterioration of symptoms)
Decision support Provider training (GP) on guidelines for the treatment of index conditions/adjustment of treatment regimens in case of co-occuring conditions
Provider training on polypharmacotherapy in the elderly
Community resources Link to existing local resources (e.g., smoking cessation programs, physical exercise programs, self-help groups)
Delivery system design Involvement of HCAs in assessment and proactive telephone follow up
Collaborative discharge planning between hospital doctors and GPs/HCAs
Healthcare organization Financial incentives for HCAs and GPs