Table 1 Elements of the planned care management intervention
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 |