The delivery of care to people with chronic conditions requires not only determining what care is needed, but clarifying roles and tasks to ensure the patient gets the care; making sure that all the clinicians who take care of a patient have centralized, up-to-date information about the patient’s status; and making follow-up a part of standard procedure.
In a well-designed delivery system, clinicians plan visits well in advance, based on the patient’s needs and self-management goals. During "group visits," patients see their clinician and meet with other patients with similar health problems. Nonphysician staff are cross-trained to provide care via standing orders.
Changes for Improvement