Chronic Care Model, health care centre

1
Chronic Care Model, health care centre
Appointment / reception

Laboratory
Nurse visit
GP visit
Goals achieved No symptoms Self care assessment
GOOD HbA1c lt6,5-7,5 or fasting glucose lt 6 LDL lt
2,6 mmol/l RR lt 140/85(130/80) nU-alb lt20
Mediocre balance e.g. Self care assessment
MEDIOCRE HbA1c 7-8 , LDL 2,6-3,5 sRR 140-160
PEF/spirometry not as recomm.
Poor balance e.g. Self care assessment
POOR HbA1c gt 8 , LDL gt 3,6 RR gt 160/95, nU-alb
gt 200 PEF/spirometry poor
Groups
EMPOVERED PATIENT
Treatment plan

• Intensify treatment
• (More) support for self care
• Change medication (update drug list)
• Visit interval and content according to change
  potential

• Continue present
• treatment
• Yearly prescriptions
• Update drug list

Self care and peer support
Self care desks
12-(24) mo
6-12 mo
2-6 mo
Handouts and forms
Planned visits to support achieve goals
Updated 26.02.08
Ask or give feedback
2
Chronic Care Model follow-up visits
Advice
Self care assessment
GP
Conclusion, plan
Information system Treatment plan