/ 20 1 Saudi Diploma in Family Medicine Center of Post Graduate Studies in Family Medicine nciples of Family Medi ciples of Family Medi Chronic Disease Management Chronic Disease Management Dr. Zekeriya Aktürk [email protected] www.aile.net
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Saudi Diploma in Family Medicine Center of Post Graduate Studies in Family Medicine
Principles of Family MedicinePrinciples of Family Medicine
Chronic Disease ManagementChronic Disease Management
Dr. Zekeriya Aktü[email protected]
www.aile.net
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30 %30 %
Top 10 cause of Death in KSA
1-Al Balla SR,. J Trop Med Hyg 1993;96:157-62 2-Bamgboye EA, Saudi Med J 1993;13(1):8-13.
/ 203Journal of Hypertension 2005, Vol 23 No 6
Hypertension
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•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
Dyslipidemia
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Obesity
/ 207Journal of Hypertension 2005, Vol 23 No 6
Smoking
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Usual Care
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Informed,Activated
Patient
ProductiveInteractions
Prepared,Proactive
Practice Team
DeliverySystemDesign
DecisionSupport
ClinicalInformation
Systems
Self-Management
Support
Health System
Resources and Policies
Community
Health Care Organization
Chronic Care ModelChronic Care Model
Improved Outcomes
/ 2010
Informed,Activated
Patient
ProductiveInteractions
PreparedPractice
Team
Essential Element of Good Chronic Illness Care
/ 2011
Informed,Activated
Patient
They have the motivation, information, skills,They have the motivation, information, skills, and confidence necessary to and confidence necessary to
effectively make decisions abouteffectively make decisions about their health and manage it.their health and manage it.
What characterizes an “informed, activated patient”?
/ 2012
PreparedPractice
Team
At the time of the interaction they have At the time of the interaction they have the patient information, decision support, and the patient information, decision support, and
resources necessary to deliver resources necessary to deliver high-quality care. high-quality care.
What characterizes a “prepared” practice team?
/ 2013
• 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.
Self-Management Support
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• Define roles and distribute tasks among team members.
• Use planned interactions to support evidence-based care.
• Provide clinical case management services for high risk patients.
• Ensure regular follow-up.• Give care that patients understand and that fits
their culture.
Delivery System Design
/ 2015
• 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.
Features of Case Management
/ 2016
• 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.
Decision Support
/ 2017
• 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.
Clinical Information Systems
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• Encourage patients to participate in effective programs.
• Form partnerships with community organizations to support or develop programs.
• Advocate for policies to improve care.
Community Resources and Policies
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• 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.
Health Care Organization
/ 2020
Informed,Activated
Patient
ProductiveInteractions
Prepared,Proactive
Practice Team
DeliverySystemDesign
DecisionSupport
ClinicalInformation
Systems
Self-Management
Support
Health System
Resources and Policies
Community
Health Care Organization
Chronic Care ModelChronic Care Model
Improved Outcomes
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