Saudi Diploma in Family Medicine Center of Post Graduate Studies i n F amily M edicine

1. Principles of Family Medicine Chronic Disease Management Saudi Diploma in Family Medicine Center of Post Graduate Studies in Family Medicine Dr. Zekeriya Aktürk zekeriya.akturk@gmail.com www.aile.net / 20

2. Top 10cause of Death in KSA 30 % 1-Al Balla SR,. J Trop Med Hyg 1993;96:157-62 2-Bamgboye EA, Saudi Med J 1993;13(1):8-13. / 20

3. Hypertension Journal of Hypertension 2005, Vol 23 No 6 / 20

4. Dyslipidemia • The overall prevalence of hypercholesterolemia TC > 200 mg/ dL: 35.4% . • The overall prevalence of hypertriglyceridemia TG > 150 mg/ dL) : 49.6%. • HDL Values in men and women Men <40mg/dL: 74.8 % Women <50mg/dL: 81.8 Al-Nozha MM.et al. Metabolic syndrome in Saudi Arabia. Saudi Med J 2005; 26 (12): 1918-1925 / 20

5. Obesity / 20

6. Smoking Journal of Hypertension 2005, Vol 23 No 6 / 20

7. Usual Care / 20

8. Chronic Care Model Community Health System Health Care Organization Resources and Policies ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Improved Outcomes / 20

9. Essential Element of Good Chronic Illness Care Prepared Practice Team Informed, Activated Patient Productive Interactions / 20

10. Informed, Activated Patient What characterizes an “informed, activated patient”? They have the motivation, information, skills, and confidence necessary to effectively make decisions about their health and manage it. / 20

11. What characterizes a “prepared” practice team? Prepared Practice Team At the time of the interaction they have the patient information, decision support, and resources necessary to deliver high-quality care. / 20

12. Self-Management Support • Emphasize the patient's central role. • Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving, and follow-up. • Organize resources to provide support. / 20

13. Delivery System Design • Define roles and distribute tasks among team members. • Use planned interactions to support evidence-based care. • Provide clinical case management services for high risk patients. • Ensure regular follow-up. • Give care that patients understand and that fits their culture. / 20

14. Features of Case Management • Regularly assess disease control, adherence, and self-management status. • Either adjust treatment or communicate need to primary care immediately. • Provide self-management support. • Provide more intense follow-up. • Provide navigation through the health care process. / 20

15. Decision Support • Embed evidence-based guidelines into daily clinical practice. • Integrate specialist expertise and primary care. • Use proven provider education methods. • Share guidelines and information with patients. / 20

16. ClinicalInformation Systems • Provide reminders for providers and patients. • Identify relevant patient subpopulations for proactive care. • Facilitateindividual patient care planning. • Share information with providers and patients. • Monitor performance of team and system. / 20

17. Community Resources and Policies • Encourage patients to participate in effective programs. • Form partnerships with community organizations to support or develop programs. • Advocate for policies to improve care. / 20

18. Health Care Organization • Visibly support improvement at all levels, starting with senior leaders. • Promote effective improvement strategies aimed at comprehensive system change. • Encourage open and systematic handling of problems. • Provide incentives based on quality of care. • Develop agreements for care coordination. / 20

19. Chronic Care Model Community Health System Health Care Organization Resources and Policies ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Improved Outcomes / 20