From: A successful chronic care program in Al Ain-United Arab Emirates
Stage | Intervention | Details/Strategies | Aim of intervention |
---|---|---|---|
I. Assessment | Flow Audit | Snapshot of 1-3 days in all centers over all hours covered and of all services | To study patient service mismatch |
 | Prevalence Study | Prevalence of conventional CVD risk factors assessed | Quantify problem in community served |
 | Care of Chronic Disease Audit | Chart audit of care of DM & HTN | Determine baseline measures of process and outcome of care for the population studied |
II. Evolving Intervention | Audit Feedback | Presentation of the audit results with document of audit summary distributed in a CME presenting recommended care as well. | Stat current practice for the HCP for awareness and reflection and to facilitate uptake of change |
 | Educational Meetings | Ongoing educational activities through CME/CNE/workshops for doctors and nurses that focused on the different aspects of the project | Venue to disseminate audit feedback and guidelines |
 | Piloting | Tailored intervention piloted in one of the centers and regularly audited including repeat of patient flow study | Trial of the intervention on small scale that can be monitored and adjusted easily and further to use it as a successful example to facilitate change of other centers |
 | Administration | Leadership commitment Multidisciplinary participation | To ensure commitment, support and ongoing follow up. |
 |  | Overall coordinator assigned |  |
 |  | Facilitators for the different tasks |  |
III. Intervention | Decision Making Aids and Tools | Follow-up sheets in the chart (colour coded) with reminders of recommended standard of care | To ensure adherence by reminders during consultation and decrease variability |
 |  | Clinical Practice Guidelines distributed | To ensure implementing evidence based practice and decrease variability |
"The structured Care" | Â | Daily appointment based clinics for DM and HTN patients | To provide protected time for the doctor and patients in clinics preset according to recommended care. |
 | System Change | Open access to laboratory and drug formulary | To support and facilitate adherence |
 |  | Calling reminder system of appointments. | To increase show rate in clinics |
 |  | Accessibility daily to lab at the point of care in all centers | To support and facilitate adherence |
 | Information | Implementing diabetic and hypertensive Evidence-Based Guidelines through the work of the local Clinical Practice Guidelines Working Group | To ensure implementing evidence-based practice and decrease variability. The guidelines adapted by local group giving the ownership to the documents. |
 | Educational Support | Educational activities through CME/CNE/workshops for doctors and nurses | To introduce the project tools as guidelines and compare them to the feedback from their practice. Also to cover areas needing increased awareness. |
 | Self-Management | Hand held booklet with the patient essential data as agreed on targets for important measures and latest tests result and changes in medications | To empower the patient to be active in the management of his illness. |
 |  | Health Education Facilitator: Health educationist started weekly visits supervising staff involved in the clinics and to emphasis on Self-Management issues |  |
 |  | Issuing of free blood glucose monitoring devices for home monitoring |  |
 |  | Introducing health education forms |  |
IV. Maintenance and Intervention review | Audit & Feedback | Regular Audits with at least one major audit covering all centers yearly | To monitor progress and give feedback to the centers |
 | HCP feedback | Continuous communication between implementation team and the HCP in the centers | To ensure compliance and solve any emerging problems |
 | Patient Feedback | During visits and satisfaction questionnaire | Patient feedback is important measure |