General Principles of Good Chronic y Care
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General Principles
of Good Chronic y
Care - extracted text
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General Principles
of Good Chronic y
Care
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INTEGRATED
MANAGEMENT OF
ADOLESCENT AND ADULT
ILLNESS
August 2004
INTERIM GUIDELINES FOR
FIRST-LEVEL FACILITY HEALTH WORKERS
TREAT
World Health Organization
03920
GENERAL PRINCIPLES OF GOOD CHRONIC CARE
This is one of 4 IMAI modules relevant for HIV care:
❖ Acute Care (including opportunistic infections, when to suspect
and test for HIV, prevention).
Chronic HIV Care with ARVTherapy.
❖ General Principles of Good Chronic Care.
❖ Palliative Care: Symptom Management and End-of-Life Care.
© World Health Organization 2004
This module. General Principles of Good Chronic Care, was prepared by the IMAI team with
special input from the Health Care for Chronic Conditions team, which is located within the
Chronic Diseases and Health Promotion Department and the Noncommunicable Diseases
and Mental Health Cluster.
This module is part of a larger strategy, the Integrated Management of Adolescent/Adult
Illness (IMAI). IMAI extends the benefits of integrated essential care, which is already available
for children and pregnant women, to the relatively neglected adolescent and adult groups
using an integrated approach based on standardized guidelines.This integrated approach
will assist health workers to identify and efficiently manage the most common health
problems.
For more information about IMAI, please see http://www.mayeticvillage.com/who-cds-imai
or contact imaimail@who.int.
Please send your suggestions how to improve this module to: cch@who.int.
CHRONIC CARE
General Principles of Good Chronic Care
These general principles of good chronic care are relevant to the
management of all chronic conditions and their risk factors.
P3
Chronic care based at the primary-care facility
near the patient's home
CLINICAL TEAM
First-level facility health workers
or health workers/lay staff at
district clinic
Clinicians at district
clinic/hospital
Diagnose
Assess, refer patient with
suspected chronic illness
Exception: initiate
treatment without
referral if:
Develop
Treatment Plan
• TB treatment with
positive sputums, or
• Leprosy if characteristic
skin lesions
Follow-up
• ARV therapy in patients
without complications
(see Chronic HIV care
module)
Modify
diagnoses or
Treatment Plan
as needed
Treat according to
Treatment Plan
Refer back for
scheduled follow-up for
exacerbations/poor control
of Treatment Plan
Hospitalize
when indicated
Do regular follow-up as
described in Treatment
Plan
Treat acute
exacerbations
P4
Manage severe
exacerbations
Good communication
General Principles of Good Chronic Care
These principles can be used in managing
many diseases and risk conditions.
1.
Develop a treatment partnership with
your patient.
2.
Focus on your patient's concerns and
priorities.
3.
Use the 5 A's:
Assess, Advise, Agree, Assist and
Arrange.
4.
Support patient self-management.
5.
Organize proactive follow-up.
6.
Involve "expert patients," peer
educators and support staff in your
health facility.
7.
Link the patient to community-based
resources and support.
8.
Use written information—registers,
Treatment Plan, treatment cards and
written information for patients—to
document, monitor and remind.
9.
Work as a clinical team.
10.
Assure continuity of care.
P5
Coordinated Approach to Chronic Care
Community partners:
Clinicians at district dinic/hospital
❖ Support patient goals
and action plans.
❖ Perform in-depth assessment, diagnose
❖ Provide care and
support to patient and
family.
❖ Collaboratively agree upon Treatment Plan
❖ Provide resources
to support patient
self-management,
including peer support
groups.
Health workers at the first-level facility:
❖ Elicit patient's goals for care
❖ Revise Treatment Plan as needed
(This could be a district clinic/peripheral health centre.)
❖ Function as treatment
buddies.
❖ Link with health
care team and
follow-up
periodically.
Elicit patient’s concerns.
Assess patient's clinical condition.
Assess readiness to adopt indicated treatments.
Exchange information about health risks.
Refer to clinician for further diagnostic work
and Treatment Plan, if indicated.
Arrange for agreed follow-up.
Reinforce patient's self-management efforts.
Maintain disease registry and treatment
cards.
Involve peer educators/"expert
patients".
Link with community partners and
follow up periodically.
Patients and Families
Patients and families
❖ Present concerns.
❖ Discuss goals for care.
❖ Negotiate a plan of care with provider/team.
❖ Manage their condition(s).
❖ Self-monitor key symptoms and treatments.
❖ Return for follow-up according to agreed plan.
P6
Steps to Guide the Chronic Care Consultation
Use the 5 A's at every patient consultation
INITIAL CONSULTATION
ASSESS
❖ Assess patient's goals for this consultation.
❖ Assess patient's clinical status, classify/identify relevant treatments and/or advise
and counsel.
❖ Assess risk factors.
❖ Assess patient's knowledge, beliefs, concerns, and daily behaviours related to
his/her chronic condition and its treatment.
ADVISE
❖ Use neutral and non-judgmental
language.
❖ Correct any inaccurate knowledge
(as assessed above) and
complete gaps in the patient's
understanding of his/her
conditions and/or risk factors and
their treatments.
If you are developing the
Treatment Plan:
• Discuss the options (risk
reduction and/or treatment)
available to the patient.
• Discuss any proposed changes
in the Treatment Plan, relating
them to the patient's specific
concerns (as assessed above).
• Evaluate the importance the
patient gives to the indicated
treatment.
• Evaluate the patient's
confidence and readiness to
adopt the indicated treatment.
Assess
"What would you like to
address today?"
"What do you know about _
(e.g., HIV/AIDS)?"
"Tell me about a typical day
including your problem and what
you are doing to manage it."
"Have you ever tried to
(e.g., change your diet)?
What was it like?"
Advise
"I have some information about
Would you like to hear it?"
.
"It has been shown that
(e.g., smoking) does great damage
to your health. What do you think
about that?"
"What questions do you have about
what I just told you?"
P7
AGREE
❖ Negotiate selection from the
different options.
Agree
❖ Agree upon goals that reflect
patient's priorities.
"Among the options we've discussed,
what would you like to do?"
Followed by: "Okay. So as I
understand it, we've agreed that
you will___. Is this correct?"
❖ Ensure that the negotiated goals are:
• Clear.
• Measurable.
• Realistic.
• Under the patient's direct control.
• Limited in number.
ASSIST
❖ Provide a written or pictorial
summary of the plan.
❖ Provide treatments.
❖ Provide medication (prescribe or
dispense).
❖ Provide other medical treatments.
❖ Provide skills and tools to assist with
self-management and adherence.
❖ Provide adherence equipment
(e.g., pill box by day of week).
• Self-monitoring tools (e.g.,
calendar or other ways to remind
and record Treatment Plan).
Assist
"What problems might arise when
you follow this plan? How do you
think you could handle that?"
"What questions do you have about
the plan or how to follow it?"
"Could you explain back to me
in your own words what you
understand that the plan is?"
Arrange
"I would like to see you again (specify
date if possible) to assess how
you're doing. It's important that
you come for this follow-up even if
you're feeling well."
❖ Address obstacles.
❖ Provide psychological support as
needed.
• Help patients to predict possible
barriers to implementing the plan and to identify strategies to overcome them.
• If patient is depressed, treat depression.
❖ Link to available support:
• Friends, family.
• Peer support groups.
• Community services.
• For certain treatments, treatment supporter or guardian.
ARRANGE
❖ Arrange follow-up to monitor treatment progress and to reinforce key messages.
❖ Schedule for group appointments or relevant support groups if available.
❖ Record what happened during the visit.
P8
FOLLOW-UP VISIT
ASSESS
Assess
❖ Assess patient's goals for this consultation.
❖ Assess patient's clinical status.
❖ Assess risk factors.
❖ Compare assessment findings with those from
previous examination and discuss with patient.
❖ Assess patient's understanding of the
Treatment Plan.
❖ Assess patient's adherence to the Treatment
Plan (by asking, counting pills, checking
pharmacy records). If adherence problem,
explore the reasons and obstacles to
adherence (including depression).
|
"To ensure we have the
same understanding,
could you tell me about
the Treatment Plan in
your own words?"
I
To assess adherence:
"Many people have trouble
taking their medications
regularly. What trouble
are you having?"
❖ Acknowledge patient's efforts and successes
with self-management, even if they are limited.
ADVISE
❖ Repeat key information concerning the patient's condition and its treatment.
❖ Reinforce what patient needs to know to self-manage:
• Symptoms, when to change treatment or to seek care.
• Treatment (why it is important; why adherence is necessary).
• Problem-solving skills.
• How to monitor one's own care.
• How and where to seek support in the community.
AGREE
❖ Negotiate changes in the plan as needed (for some conditions, a revised
Treatment Plan might require a return visit to the district clinician).
ASSIST
❖ Address problems or "slips" with the following Treatment Plan; teach patient how
to solve problems and learn from them.
❖ Discuss problems that occurred in adherence and develop strategies to
overcome them in the future.
ARRANGE
❖ Arrange follow-up to monitor treatment progress and to reinforce key messages.
(These should be part of a programme of care over time.)
❖ Schedule for group appointments or relevant support groups, if available.
❖ Record what happened during the visit.
P9
TDFS
Tips for talking with the patient:
❖ Express understanding and acceptance.
❖ Avoid arguments.
❖ Respect the patient's right to choose.
Tips for involving "expert patients" on the clinical team:
❖ Choose patients who:
• understand their disease well;
• are good communicators;
• are respected by other patients; and
• have time to be involved on a regular basis.
❖ Ensure they understand and will respect shared confidentiality.
❖ Ensure they do not exceed their expertise or areas of responsibility.
Tips for group appointments:
Group appointments can help you make the most of scarce time.
❖ Use group appointments to:
• educate patients about their conditions;
• develop peer support and expertise;
• promote self-management;
• conduct clinical follow-up; and
• address difficulties.
❖ Use peer educators or "expert patient" to help organize group
appointments and to present educational material.
Tips for team meetings:
The purpose of team meetings is to communicate, to share efficiently
patient information and Treatment Plans, and to share responsibility for all
aspects of care and outcomes.
❖ Discuss only a subset of patients each week.
' ❖The team leader should prepare weekly patient list and agenda.
< ❖Develop among the team a consistent understanding of each patient's
1
goals, the Treatment Plan and key messages to be delivered by the team
' members.
^JSE WRITTEN INFORMATION
• • •11
’Written information helps to:
❖ Remember the Treatment Plan.
❖ Monitor and evaluate progress.
❖ Remember when it's time for a follow-up appointment and facilitate
response to missed appointments.
❖Transfer pertinent information to others.
❖ Arrange for supportive care from community resources.
Written information for patients:
Written or pictorial information helps patients remember the plan and
monitor their self-management.
❖ Provide patient with a written or pictorial summary of the plan to take
home.
❖ Provide patients with self-monitoring tool such as a calendar or chart.
❖ Review patient self-monitoring tools at each follow-up visit.
Tips for keeping health facility records:
Complete registers by the end of each day.
❖ Keep Treatment Plans/cards in a file box, divided by date of the planned
follow-up visit.
❖ Ensure that registers and cards are kept in a secure and confidential
location.
GOOD COMMUNICATION
Communicating with clinicians at the district hospital/clinic:
❖These clinicians are part of your clinical team. If you are in a peripheral
facility, methods need to be developed for good communication and at
least yearly meetings.
❖ Communicate with district hospital/clinic concerning all chronic
patients, even when treatment is initiated at the first-level facility.
❖ Coordinate care with appropriate clinic/clinicians.
❖ Refer patients back to clinicians as appropriate.
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