Table 3

Summary of common model elements and approaches to inform models of lifelong care for chronic conditions for children and adolescents

Care components
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.

Comprehensive care
  • Multidisciplinary care to effectively coordinate chronic care for children and adolescents with roles for case manages or care coordinators to develop and oversee care teams.

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.

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.

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.

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.

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.

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.

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.

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.