Question

• Provide steps you would use to incorporate a team-based approach for managing chronic care patients. Discuss who and why you would include certain specialties or persons as part of your interdisciplinary team.

Answer 1

STEPS TO INCORPORATE A TEAM BASED APPROACH FOR MANAGING CHRONIC CARE PATIENTS.

1. CREATE AN ORGANISATION THAT PROVIDE SAFE AND HIGH QUALITY CARE.(HEALTH SYSTEM).
2. MOBILIZE COMMUNITY RESOURCES TO MEET THE NEEDS OF THE PATIENTS.(THE COMMUNITY)
3. EMPOWER PATIENTS TO MANAGE THEIR HEALTH CARE.( SELF MANAGEMENT SUPPORT)
4. ASSURE EFFECTIVE ,EFFICIENT CARE AND SELF MANAGEMENT SUPPORT.(DELIVERY SYSTEM DESIGN)
5. PROMOTE CARE CONSISTENT WITH SCIENTIFIC DATA AND PATIENT PREFERENCES.
6. ORGANISE DATA TO FACILITATE EFFICIENT AND EFFECTIVE CARE.(CLINICAL INFORMATIVE SYSTEMS)   

• INTERDISCIPLINARY TEAM
• Licensed pratical nurse or registered nurse-manage patients by protocol ,adding clinical and self managing skills as well as greater intesity of care.
• Medical specialist-who can manage cases of respective specialities.
• Clinical pharmacists-optimising drug regimens to reduce adverse effects and increase efficiency.
• Social workers-accquisition of community resources and integration of patients back into the community.
• Lay health workers-community health workers have role in bridging the language and cultural gaps between middle class health professionals and ethically and culturally different patient population.