Skip to main content

Table 1 The major components of the project, including organizational interventions and interventions targeting both patients and health care professionals

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"

 

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