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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.