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Table 1 Chronic Care Model elements and respective strategies

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

Model Elements Approaches/Strategies
Self-Management Support - Emphasize the patient’s central role in managing their health - Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving and follow-up - Organize internal and community resources to provide ongoing self-management support to patients
Community - 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 - Visibly support improvement at all levels of the organization, beginning with the senior leader. - Promote effective improvement strategies aimed at comprehensive system change. - Encourage open and systematic handling of errors and quality problems to improve care. - Provide incentives based on quality of care. - Develop agreements that facilitate care coordination within and across organizations
Delivery System Design - 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. - Give care that patients understand and that fits with their cultural background
Decision Support - Embed evidence-based guidelines into daily clinical practice. - Share evidence-based guidelines and information with patients to encourage their participation. - Use proven provider education methods. - Integrate specialist expertise and primary care
Clinical Information System - Provide timely reminders for providers and patients. - Identify relevant subpopulations for proactive care. - Facilitate individual patient care planning. - Share information with patients and providers to coordinate care. - Monitor performance of practice team and care system.