| Patient and family education and involvement | Age-appropriate disease-based education. Resources to support lifestyle changes such as self-monitoring calendars or alarm clocks. Training materials and curricula to teach healthcare providers how to educate patients and families on disease-specific clinical management and how to support their self-management skills.
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| Comprehensive care | |
| Multisectoral linkages | Leveraging accessible, existing social support and community-based resources to complement clinical care. Stakeholder groups to ensure activities are locally-driven and responsive to local needs and available resources.
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| Mental health and psychosocial support | Community-driven campaigns to raise awareness for chronic conditions and reduce and prevent stigma. Multidisciplinary teams which include social workers, case managers, psychologists, counsellors, etc to address patients’ psychosocial well-being. Social support staff included in trainings on chronic disease management for children and adolescents to equip them to predict, understand and respond to patients’ needs. Peer groups or peer educators incorporated into care plans, particularly for adolescents’ who are highly susceptible to peer influence and social environments.
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| Service delivery |
| Decentralising services and task shifting | Increased capacity in the primary care setting for integrated chronic disease care including improvement of general infrastructure to accommodate increased patient volume. Optimised clinical flow in primary care settings by reassigning roles for routine screenings and stable patient follow-up to less specialised healthcare workers with the appropriate training.
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| Flexible, simplified and proactive patient care | Proactive outreach to patients to promote routine chronic disease management such as appointment reminders via text, home-based care for routine follow-up or medication delivery, and extended clinic hours that align with patients’ non-working or school hours. Bundled services to decrease patients’ burden such as the number of clinic visits required or telephone management offered for routine check-ups.
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| Differentiated care | Risk profiles assigned so that patients’ level of care and frequency of follow-up correspond with their clinical needs and preferences Regularly monitoring patient satisfaction to assess quality of care Provider training in child and adolescent development and behaviour to ensure that level of care matches a patient’s capacity for self-management.
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| Resources invested |
| Health worker training | Training for different levels of expertise (eg, physicians, nurses, social workers) on the treatment of specific chronic conditions to support the ‘upskilling’ of primary care providers and lay personnel. Routine training and refresher courses to incorporate changing guidelines and any newly developed interventions into routine care.
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| Physical space | Primary care facility capacity for internet access, point-of-care technologies, increased laboratory services and adequate clinical space to enable comprehensive chronic disease care in a primary care setting.
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| Information systems and technology | mHealth and eHealth interventions including mobile phones for text message reminders, smart phone applications for tracking adherence, symptoms and supporting ongoing education. Clinical information systems for patient tracking such as nationwide electronic medical records which are designed to incorporate chronic care screening, testing and treatment data.
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