慢性病照料模型工具Chronic care model tools【国外优秀研究报告】.ppt

Chronic care model tools Pam Allweiss MD, MPH (pca8@) Consultant CDC Division of Diabetes Translation Faculty: University of Kentucky Examples of Tools, Checklists, Patient Education Small steps: Big rewards Can’t transform everything at once Use the web sites to print out forms and “recipes” Don’t re-invent the wheel Learn from others Examples of Patient responsibilitieschecklist Exercise program Monitoring of blood glucose Adherence to the system of intensive self-management Adherence to dietary guidelines Treating and modifying “targets” in collaboration with physician Endocrine pract. 8:supl 1 2002 Patient Responsibilities Smoking cessation Consistent use of aspirin Overcoming psychological and other barriers Healthy expression of feelings Foot and eye care Knowledge of personal glycosylated hemoglobin value and its significance Endocrine pract. 8:supl 1 2002 Physician Responsibilities Measurement of outcomes Development of evaluation programs; include safety in taking meds Blood pressure monitoring Determination of patient satisfaction Maintenance of communication with team Listening to patient concerns Encouragement of patient in use of preventive measures Record keeping and risk reduction Endocrine pract. 8:supl 1 2002 Self-Management Support ToolHEALTHY CHANGES PLAN The healthy change I want to make is (very specific: What, When, How, Where, How Often): My goal for the next month is: The steps I will take to achieve my goal are: The things that could make it difficult to achieve my goal include: My plan for overcoming these difficulties includes: Support/resources I will need to achieve my goal include: My confidence that I can achieve my goal: (scale of 1-10 with 1 being not confident at all, 10 being extremely confident) Self Management Tools: Green Zone- Good HbA1c is under 7 Average blood sugars typically under 150 Most fasting blood sugars under 150 Your blood sugars are under control Continue taking your medications as or