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Principles of Family Medicine Chronic Disease Management. Saudi Diploma in Family Medicine Center of Post Graduate Studies i n F amily M edicine. Dr. Zekeriya Aktürk zekeriya.akturk@gmail.com www.aile.net. Top 10 cause of Death in KSA. 30 %.

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slide1

Principles of Family Medicine

Chronic Disease Management

Saudi Diploma in Family Medicine

Center of Post Graduate Studies in Family Medicine

Dr. Zekeriya Aktürk

zekeriya.akturk@gmail.com

www.aile.net

/ 20

top 10 cause of death in ksa
Top 10cause of Death in KSA

30 %

1-Al Balla SR,. J Trop Med Hyg 1993;96:157-62 2-Bamgboye EA, Saudi Med J 1993;13(1):8-13.

/ 20

hypertension
Hypertension

Journal of Hypertension 2005, Vol 23 No 6

/ 20

d yslipidemia
Dyslipidemia
  • The overall prevalence of hypercholesterolemia

TC > 200 mg/ dL: 35.4% .

  • The overall prevalence of hypertriglyceridemia

TG > 150 mg/ dL) : 49.6%.

  • HDL Values in men and women

Men <40mg/dL: 74.8 %

Women <50mg/dL: 81.8

Al-Nozha MM.et al. Metabolic syndrome in Saudi Arabia. Saudi Med J 2005; 26 (12): 1918-1925

/ 20

smoking
Smoking

Journal of Hypertension 2005, Vol 23 No 6

/ 20

slide8

Chronic Care Model

Community

Health System

Health Care Organization

Resources and Policies

ClinicalInformationSystems

Self-Management Support

DeliverySystem

Design

Decision

Support

Prepared,

Proactive

Practice Team

Informed,

Activated

Patient

Productive

Interactions

Improved Outcomes

/ 20

essential element of good chronic illness care
Essential Element of Good Chronic Illness Care

Prepared

Practice

Team

Informed,

Activated

Patient

Productive

Interactions

/ 20

what characterizes an informed activated patient

Informed,

Activated

Patient

What characterizes an “informed, activated patient”?

They have the motivation, information, skills,

and confidence necessary to

effectively make decisions about

their health and manage it.

/ 20

what characterizes a prepared practice team
What characterizes a “prepared” practice team?

Prepared

Practice

Team

At the time of the interaction they have

the patient information, decision support, and

resources necessary to deliver

high-quality care.

/ 20

self management support
Self-Management Support
  • Emphasize the patient's central role.
  • Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving, and follow-up.
  • Organize resources to provide support.

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delivery system design
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 high risk patients.
  • Ensure regular follow-up.
  • Give care that patients understand and that fits their culture.

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features of case management
Features of Case Management
  • Regularly assess disease control, adherence, and self-management status.
  • Either adjust treatment or communicate need to primary care immediately.
  • Provide self-management support.
  • Provide more intense follow-up.
  • Provide navigation through the health care process.

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decision support
Decision Support
  • Embed evidence-based guidelines into daily clinical practice.
  • Integrate specialist expertise and primary care.
  • Use proven provider education methods.
  • Share guidelines and information with patients.

/ 20

clinical information systems
ClinicalInformation Systems
  • Provide reminders for providers and patients.
  • Identify relevant patient subpopulations for proactive care.
  • Facilitateindividual patient care planning.
  • Share information with providers and patients.
  • Monitor performance of team and system.

/ 20

community resources and policies
Community Resources and Policies
  • Encourage patients to participate in effective programs.
  • Form partnerships with community organizations to support or develop programs.
  • Advocate for policies to improve care.

/ 20

health care organization
Health Care Organization
  • Visibly support improvement at all levels, starting with senior leaders.
  • Promote effective improvement strategies aimed at comprehensive system change.
  • Encourage open and systematic handling of problems.
  • Provide incentives based on quality of care.
  • Develop agreements for care coordination.

/ 20

slide19

Chronic Care Model

Community

Health System

Health Care Organization

Resources and Policies

ClinicalInformationSystems

Self-Management Support

DeliverySystem

Design

Decision

Support

Prepared,

Proactive

Practice Team

Informed,

Activated

Patient

Productive

Interactions

Improved Outcomes

/ 20