Table 1 Indicators area and components
Area | Components |
|---|---|
Change Management | Decision makers support (PHC director and managers) |
Leader for the implementation of the MPCM at the PHC | |
Local training plan of MPCM for new employees | |
Operational | Adult population stratified by risk, available and with patients ID |
Unified drug prescription | |
Alert system informing PHC teams of patients consulting at emergency room and hospitalization | |
Integrated multimorbidity scheduled appointments | |
New Roles | Clinical Pharmacist |
High-Risk primary physician | |
Case Manager | |
Transition Nurse | |
Activities and services | Individualized Care Plans |
Phone counseling | |
Continuity of care with a professional from the team | |
Rescue after hospital discharge | |
Implementation of an induction plan | |
Transition care |