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Table 3 CCM elements evidence in AHS

From: The primary health care in the emirate of Abu Dhabi: are they aligned with the chronic care model elements?

Model Elements

Evidence in Primary Healthcare Centers

Gaps

Self-Management Support

Through Health Education in SEHA’s website and App:

- Information about the importance of patients decisions and daily routines that affect their health and specifically according with the disease;

- Information available about how to manage the types of Diabetes, Heart and Circulation Diseases, Kidney Diseases and Health Lifestyle

Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving and follow-up

Community

- SEHA is establishing electronic programs and communication channels (interactive when possible).

- In 2013, lectures on health and nutrition were delivered for family foundation development schools.

- Encourage patients to participate in effective community programs;

- Form partnerships with community organizations to support and develop interventions that fill gaps in needed services;

- Advocate for policies to improve patient care

Health System

- In 2013 SEHA launched the National Hospital Quality Measure;

- Provides performance data to the different professions;

- Set out procedures that will create shared responsibility for individuals towards their duties.

- Provides incentives based on quality of care;

- Names and rewards outstanding individual contributors in different categories;

- Each SEHA’s hospital have linked Ambulatory Healthcare Services;

- SEHA establishes partnerships with healthcare providers to ensure the accessibility (e.g. Jonh Hopkins Hospital, Cleveland Clinic)

- Promote effective improvement strategies aimed at comprehensive system change;

- Visibly support improvement at all levels of the organization, beginning with the senior leader;

Delivery System Design

- Care Plans;

- Give care that patients understand and that fits with their cultural background

- Define roles and distribute tasks among team members;

- Use planned interactions to support evidence-based care;

- Provide clinical case management services for complex patients;

- Ensure regular follow-up by the care team;

Decision Support

- In 2013, SEHA launched “Kafu”, consumer care development program to standardize costumer care by adopting the best practice;

- Provides useful and specialized data;

- SEHA offers interactive tutorials, videos, PDF’s and quizzes about the topics in Health Education;

- Integrative teams with specialist expertise in primary care (ex: Dieticians following up diabetes patients in ambulatory centers)

- Embed evidence-based guidelines into daily clinical practice;

- Share evidence-based guidelines and information with patients to encourage their participation;

Clinical Information System

- In case of patients with health disease SEHA facilitates an emergency plan that the patient must know;

- The patients information is available in SEHA database and any clinic can see it when its needed;

- The PCMH dash board has graphs, charts and spreadsheets about chronic disease patients and doctors performance;

- Identify relevant subpopulations for proactive care;

- Provide timely reminders for providers and patients;

- Share information with patients and providers to coordinate care;

- Monitor performance of practice team and care system.