WHO/CDS/IMAI/2004.3 Rev. 1
General Principles of Good Chron ic Care
INTEGRATED MANAGEMENT OF ADOLESCENT AND ADULT ILLNESS
INTERIM GUIDELINES FOR FIRSTLEVEL FACILITY HEALTH WORKERS August 2004 August 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 ARV Therapy. CHRONIC CARE General Principles of Good Chronic Care. General Principles of Good Chronic Care Palliative Care: Symptom Management and End-of-Life Care. These general principles of good chronic care are relevant to the management of all chronic conditions and their risk factors.
© 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 benefi ts 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 effi ciently manage the most common health problems.
For more information about IMAI, please see http://www.mayeticvillage.com/who-cds-imai or contact [email protected].
Please send your suggestions how to improve this module to: [email protected].
P2 P3 General Principles of Good Chronic Care Chronic care based at the primary-care facility near the patient’s home
CLINICAL TEAM These principles can be used in managing many diseases and risk conditions. The 5 A’s First-level facility health workers Clinicians at district 1. Develop a treatment partnership with or health workers/lay staff at clinic/hospital your patient. district clinic Diagnose 2. Focus on your patient’s concerns and Assess, refer patient with Consult/refer for Assess suspected chronic illness certain patients priorities. 1 Exception: initiate 3. Use the 5 A’s: treatment without Develop Assess, Advise, Agree, Assist and referral if: Treatment Plan Arrange. Advise • TB treatment with 2 positive sputums, or 4. Support patient self-management.
• Leprosy if characteristic Treatment Plan 5. Organize proactive follow-up. skin lesions Follow-up Agree • ARV therapy in patients Modify 6. Involve “expert patients,” peer 3 without complications diagnoses or educators and support staff in your (see Chronic HIV care Treatment Plan health facility. module) as needed 7. Link the patient to community-based Assist Refer back for Treat according to scheduled follow-up for resources and support. 4 Treatment Plan exacerbations/poor control Manage severe of Treatment Plan exacerbations 8. Use written information—registers, Treatment Plan, treatment cards and Hospitalize Arrange Do regular follow-up as written information for patients—to when indicated 5 described in Treatment document, monitor and remind. Plan 9. Work as a clinical team.
Good communication Treat acute 10. Assure continuity of care. exacerbations
P4 P5 Coordinated Approach to Chronic Care Steps to Guide the Chronic Care Consultation Use the 5 A’s at every patient consultation
Community partners: Clinicians at district clinic/hospital Support patient goals Perform in-depth assessment, diagnose INITIAL CONSULTATION and action plans. Elicit patient’s goals for care Provide care and Collaboratively agree upon Treatment Plan ASSESS support to patient and Revise Treatment Plan as needed Assess patient’s goals for this consultation. family. Assess patient’s clinical status, classify/identify relevant treatments and/or advise Provide resources Health workers at the fi rst-level facility: and counsel. to support patient (This could be a district clinic/peripheral health centre.) Assess risk factors. self-management, Elicit patient’s concerns. including peer support Assess patient’s knowledge, beliefs, concerns, and daily behaviours related to Assess patient’s clinical condition. groups. his/her chronic condition and its treatment. Assess readiness to adopt indicated treatments. Function as treatment buddies. Exchange information about health risks. ADVISE Assess Link with health Refer to clinician for further diagnostic work Use neutral and non-judgmental and Treatment Plan, if indicated. care team and language. "What would you like to follow-up Arrange for agreed follow-up. Correct any inaccurate knowledge address today?" periodically. Reinforce patient’s self-management eff orts. Prepared Health-Care Team (as assessed above) and "What do you know about ___ Maintain disease registry and treatment complete gaps in the patient’s (e.g., HIV/AIDS)?" cards. understanding of his/her Involve peer educators/"expert conditions and/or risk factors and "Tell me about a typical day patients". their treatments. including your problem and what Link with community partners and you are doing to manage it." If you are developing the Motivated follow up periodically. Treatment Plan: "Have you ever tried to ___ Community Partners (e.g., change your diet)? Informed • Discuss the options (risk reduction and/or treatment) What was it like?" available to the patient. Patients and Families • Discuss any proposed changes Advise in the Treatment Plan, relating Patients and families them to the patient’s specifi c "I have some information about ___. concerns (as assessed above). Would you like to hear it?" Present concerns. • Evaluate the importance the Discuss goals for care. "It has been shown that ___ patient gives to the indicated (e.g., smoking) does great damage Negotiate a plan of care with provider/team. treatment. Manage their condition(s). to your health. What do you think • Evaluate the patient’s about that?" Self-monitor key symptoms and treatments. confi dence and readiness to Return for follow-up according to agreed plan. adopt the indicated treatment. "What questions do you have about what I just told you?" P6 P7 AGREE Negotiate selection from the Agree FOLLOW-UP VISIT diff erent options. Agree upon goals that refl ect "Among the options we’ve discussed, ASSESS Assess patient’s priorities. what would you like to do?" Assess patient’s goals for this consultation. Ensure that the negotiated goals are: Followed by: "Okay. So as I Assess patient’s clinical status. "To ensure we have the understand it, we’ve agreed that same understanding, • Clear. Assess risk factors. could you tell me about • Measurable. you will ___. Is this correct?" Compare assessment fi ndings with those from the Treatment Plan in • Realistic. previous examination and discuss with patient. your own words?" • Under the patient’s direct control. Assist Assess patient’s understanding of the • Limited in number. Treatment Plan. "What problems might arise when To assess adherence: Assess patient’s adherence to the Treatment ASSIST you follow this plan? How do you Plan (by asking, counting pills, checking "Many people have trouble Provide a written or pictorial think you could handle that?" pharmacy records). If adherence problem, taking their medications summary of the plan. explore the reasons and obstacles to regularly. What trouble "What questions do you have about Provide treatments. adherence (including depression). are you having?" the plan or how to follow it?" Provide medication (prescribe or Acknowledge patient’s eff orts and successes dispense). "Could you explain back to me with self-management, even if they are limited. in your own words what you Provide other medical treatments. ADVISE understand that the plan is?" Provide skills and tools to assist with Repeat key information concerning the patient’s condition and its treatment. self-management and adherence. Reinforce what patient needs to know to self-manage: Provide adherence equipment Arrange (e.g., pill box by day of week). • Symptoms, when to change treatment or to seek care. • Self-monitoring tools (e.g., "I would like to see you again (specify • Treatment (why it is important; why adherence is necessary). calendar or other ways to remind date if possible) to assess how • Problem-solving skills. and record Treatment Plan). you’re doing. It’s important that • How to monitor one’s own care. Address obstacles. you come for this follow-up even if • How and where to seek support in the community. Provide psychological support as you’re feeling well." needed. AGREE • Help patients to predict possible Negotiate changes in the plan as needed (for some conditions, a revised barriers to implementing the plan and to identify strategies to overcome them. Treatment Plan might require a return visit to the district clinician). • If patient is depressed, treat depression. ASSIST Link to available support: Address problems or "slips" with the following Treatment Plan; teach patient how • Friends, family. to solve problems and learn from them. • Peer support groups. Discuss problems that occurred in adherence and develop strategies to • Community services. overcome them in the future. • For certain treatments, treatment supporter or guardian. ARRANGE ARRANGE Arrange follow-up to monitor treatment progress and to reinforce key messages. 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. Schedule for group appointments or relevant support groups, if available. Record what happened during the visit. Record what happened during the visit. P8 P9 TIPS USE WRITTEN INFORMATION
Tips for talking with the patient: Written information helps to: Express understanding and acceptance. Remember the Treatment Plan. Avoid arguments. Monitor and evaluate progress. Respect the patient’s right to choose. Remember when it’s time for a follow-up appointment and facilitate response to missed appointments. Tips for involving "expert patients" on the clinical team: Transfer pertinent information to others. Choose patients who: Arrange for supportive care from community resources. • understand their disease well; • are good communicators; Written information for patients: • are respected by other patients; and Written or pictorial information helps patients remember the plan and • have time to be involved on a regular basis. monitor their self-management. Ensure they understand and will respect shared confi dentiality. Provide patient with a written or pictorial summary of the plan to take Ensure they do not exceed their expertise or areas of responsibility. home. Provide patients with self-monitoring tool such as a calendar or chart. Tips for group appointments: Review patient self-monitoring tools at each follow-up visit. Group appointments can help you make the most of scarce time. Use group appointments to: Tips for keeping health facility records: • educate patients about their conditions; Complete registers by the end of each day. • develop peer support and expertise; Keep Treatment Plans/cards in a fi le box, divided by date of the planned • promote self-management; follow-up visit. • conduct clinical follow-up; and Ensure that registers and cards are kept in a secure and confi dential • address diffi culties. location. Use peer educators or "expert patient" to help organize group appointments and to present educational material. GOOD COMMUNICATION Tips for team meetings: Communicating with clinicians at the district hospital/clinic: The purpose of team meetings is to communicate, to share effi ciently These clinicians are part of your clinical team. If you are in a peripheral patient information and Treatment Plans, and to share responsibility for all facility, methods need to be developed for good communication and at aspects of care and outcomes. least yearly meetings. Discuss only a subset of patients each week. Communicate with district hospital/clinic concerning all chronic The team leader should prepare weekly patient list and agenda. patients, even when treatment is initiated at the fi rst-level facility. Develop among the team a consistent understanding of each patient’s Coordinate care with appropriate clinic/clinicians. goals, the Treatment Plan and key messages to be delivered by the team Refer patients back to clinicians as appropriate. members. P10 P11