Term
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Definition
| improved functional and clinical outcomes for disease management are the result of productive interactions between informed, activated patients and the prepared, proactive practice team of clinicians and health care professionals. |
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Term
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Definition
| evaluation of health system performance including strong health informatics, providing patients support to manage their condition, supporting patients to make health decisions, partnerships with community actors to meet the patient’s needs, and improved patient outcomes. |
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Term
| Health system organization of care |
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Definition
| programming planning that includes measurable goals for better care of chronic illness (examples = visible support of improvements provided by senior leadership and incentives for care providers) |
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Term
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Definition
| emphasis on the importance of the central role that patients have in managing their own care (example = educational resources, skills training and psychological support provided to patients to assist them in managing their care) |
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Term
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Definition
| integration of evidence based guidelines into daily clinical practice (examples = wide dissemination of practice guidelines, education and specialist support provided to health care team) |
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Term
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Definition
| focus on teamwork and an expanded scope of practice for team members to support chronic care (examples = planned visits and sustained follow-up, clearly define roles of healthcare team) |
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Term
| clinical information systems |
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Definition
| developing information systems based on patient populations to provided relevant client data (Examples = surveillance system that provides alters, recall and follow-up information; identification of relevant patient subgroups requiring proactive care) |
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Term
| community resources and policies |
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Definition
| developing partnerships with community organizations that support and meet patient’s needs (examples = identify effective programs and encourage appropriate participation; referral to relevant community-based services) |
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Term
| Expanded Chronic Care Model |
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Definition
| Clarifies and expands on the role of community in chronic care: engaged in identifying and responding to needs |
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Term
| Patient Centered Care Model |
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Definition
| providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions |
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