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Table 1 The major components of the project, including organizational interventions and interventions targeting both patients and health care professionals

From: A successful chronic care program in Al Ain-United Arab Emirates

Stage Intervention Details/Strategies Aim of intervention
I. Assessment Flow Audit Snapshot of 1-3 days in all centers over all hours covered and of all services To study patient service mismatch
  Prevalence Study Prevalence of conventional CVD risk factors assessed Quantify problem in community served
  Care of Chronic Disease Audit Chart audit of care of DM & HTN Determine baseline measures of process and outcome of care for the population studied
II. Evolving Intervention Audit Feedback Presentation of the audit results with document of audit summary distributed in a CME presenting recommended care as well. Stat current practice for the HCP for awareness and reflection and to facilitate uptake of change
  Educational Meetings Ongoing educational activities through CME/CNE/workshops for doctors and nurses that focused on the different aspects of the project Venue to disseminate audit feedback and guidelines
  Piloting Tailored intervention piloted in one of the centers and regularly audited including repeat of patient flow study Trial of the intervention on small scale that can be monitored and adjusted easily and further to use it as a successful example to facilitate change of other centers
  Administration Leadership commitment Multidisciplinary participation To ensure commitment, support and ongoing follow up.
   Overall coordinator assigned  
   Facilitators for the different tasks  
III. Intervention Decision Making Aids and Tools Follow-up sheets in the chart (colour coded) with reminders of recommended standard of care To ensure adherence by reminders during consultation and decrease variability
   Clinical Practice Guidelines distributed To ensure implementing evidence based practice and decrease variability
"The structured Care"   Daily appointment based clinics for DM and HTN patients To provide protected time for the doctor and patients in clinics preset according to recommended care.
  System Change Open access to laboratory and drug formulary To support and facilitate adherence
   Calling reminder system of appointments. To increase show rate in clinics
   Accessibility daily to lab at the point of care in all centers To support and facilitate adherence
  Information Implementing diabetic and hypertensive Evidence-Based Guidelines through the work of the local Clinical Practice Guidelines Working Group To ensure implementing evidence-based practice and decrease variability. The guidelines adapted by local group giving the ownership to the documents.
  Educational Support Educational activities through CME/CNE/workshops for doctors and nurses To introduce the project tools as guidelines and compare them to the feedback from their practice. Also to cover areas needing increased awareness.
  Self-Management Hand held booklet with the patient essential data as agreed on targets for important measures and latest tests result and changes in medications To empower the patient to be active in the management of his illness.
   Health Education Facilitator: Health educationist started weekly visits supervising staff involved in the clinics and to emphasis on Self-Management issues  
   Issuing of free blood glucose monitoring devices for home monitoring  
   Introducing health education forms  
IV. Maintenance and Intervention review Audit & Feedback Regular Audits with at least one major audit covering all centers yearly To monitor progress and give feedback to the centers
  HCP feedback Continuous communication between implementation team and the HCP in the centers To ensure compliance and solve any emerging problems
  Patient Feedback During visits and satisfaction questionnaire Patient feedback is important measure